Provider Demographics
NPI:1497261424
Name:OTERO, BENNIE JUNIOR JR
Entity Type:Individual
Prefix:MR
First Name:BENNIE
Middle Name:JUNIOR
Last Name:OTERO
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1820 SKYLARK DR
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76010-3043
Mailing Address - Country:US
Mailing Address - Phone:817-617-1221
Mailing Address - Fax:
Practice Address - Street 1:1820 SKYLARK DR
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76010-3043
Practice Address - Country:US
Practice Address - Phone:817-617-1221
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-28
Last Update Date:2017-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX82-3824286374700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374700000XNursing Service Related ProvidersTechnician
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX82-3824286Other82